Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Friday, June 29, 2007

Shoe/Foot (other)

I wish I'd had a tape-recorder. I'd have gotten it all and sent a copy to the doctors and the nurses. If I were nasty, I'd have sent it to the hospital administrator...

Having had a number of people close to me in the hospital lately, I've spent plenty of time at the bedside. It leads me to conclude that if every doctor and nurse did the same, without letting on that they were "medical," they'd change their behavior overnight. I was a visitor in a hospital just this morning, in a two person room. The roommate was a nice lady, fresh from surgical repair of a broken leg. A few months ago, she'd had breast cancer. A doctor came to see her: thin, dressed in a crispy thigh-length white coat, dark slacks, academically correct glasses. Medical guy, clearly.

"Hello," he said. "How are you feeling?""Hi. I'm ok, I ....""I saw your scan. It doesn't show the cancer. Does it hurt when I press here on your liver?""That doesn't hurt, but...""Are you feeling better than yesterday? Does your liver hurt when I push here?""A little, maybe...""OK." Exits.

Seriously. That was the exact interaction.

Meanwhile, the lady had called the nurse because her drain had come apart, leaking into her bed. As the nurse checked it out, she noticed what was evidently more than the usual amount of swelling in the lady's leg. "Oh, this is pretty swollen. Is it bigger than yesterday?""I don't know. I guess so, looking at it...""I'm going to call your doctor." Exits. Returns with another nurse in a couple of minutes. "Does this look swollen to you?""Yes, and it feels tight."

Someone sticks her head in the door. "You page Dr Ortho?""Yes, I'll get it." Exits, returns in a couple of minutes. "He said not to call him urgently, it scared him. He's coming." Rustling around, passing back and forth in front of me and the person I'm visiting, urgent, but no eye contact our way.

Dr. Ortho shows up in about five minutes. "Let's have a look... You have some bleeding into the muscle. It happens. We cut apart the muscle to fix the bone. And you're on blood thinners. You need to be on them, but when they cause problems, we have to stop them. We'll take out the drain. Try to lie right on the leg. The pressure will help.""Thank you, Doctor.""You're welcome. Goodbye."

Nurses return to patient, and talk while changing the bandages: "He acted like it wasn't important, like I didn't need to call him. I think it was important.""So do I. It's a problem.""Well he sure acted like it isn't.""It is."

No point in listing the issues: I assume they're obvious, and that if the people were to see or hear a playback, they'd feel bad. Nor did I say anything, because I wasn't part of it. Last time I was, I did.

When my dad was admitted for what turns out to have been his final hospitalization a couple of years ago, it was first to a room on the medical floor. (I arrived a few hours after admission, to find him working quite hard to breathe, and asked the nurse how long it'd been since his oxygen level had been checked. "It was fine when he came in, but I'll check again.... 75%. That can't be right...." But that's another story, maybe for another day.) The point was that while we were awaiting the arrival of his physician, some attending came in leading an audience of admirers, consisting of a resident, an intern, and a student. Never acknowledging my mother, who was sitting by my dad with her fear and concern as obvious as if she were on fire, the attending told my dad he was going to listen to his lungs, and did so. No introduction, no preamble. Without another word to my dad, he asked his charges to do the same, which they did, wordlessly, after which he began to talk to them about it as they exited the room. The student turned and (uncomfortable, I'd like to think, at the absence of humanity) said "thank you" as he left. "I'll be right back," I said to my folks, launching from my chair with the fury of righteous indignation thrusting me like a bottle rocket.

"Excuse me, I'm Dr Schwab, and those were my parents," I intruded into the gaggle outside the room, ignoring entirely the attending and looking only at the student. "I've been in practice over twenty-five years, and I've never seen a worse example of how to behave in front of patients and family. I hope you took notes, because it's really important, more important than whatever you heard in my dad's chest. No one introduced himself, no one explained why they were there, what was going on. If you couldn't tell my mother was scared to death, you're all blind. Yet no one acknowledged her at all. No one even turned her way. She didn't exist to those people. That was the most egregious behavior I've ever seen.... and I'm a damn SURGEON!! Maybe you can learn from this -- (still looking at the student and paying no attention to the doctors) -- I'm guessing the rest couldn't care less." As I walked back into the room, I noticed the eyes of a couple of nearby docs aimed in my direction. I don't know what they were thinking.

Docs, nurses, students: when someone you know is in a hospital where you aren't known, make it a point to visit. Watch and listen. It'll be better for you than a dozen sensitivity classes. Way better. Acknowledgment, explanations. Listening. In that first case, about twenty extra words from the docs, and twenty fewer from those nurses would have made all the difference. For all of 'em: empathy. It's all about empathy. The absence is about 90% of what's wrong with medical care. And you know what? I'll say it. I'll take a chance on sounding like a pain in the ass: I know I was never perfect. I don't have the fastest hands nor the deepest knowledge on the planet; I've made mistakes in technique and in judgment. But I always had empathy. Itreated my patients as I'd have wanted my parents to have been treated. I never acted like any of those idiots. (Not to patients, anyway.) And I'm still pissed.

BRAVO Dr. Schwab!! You had me on my feet and off of this chair reading! I had to comment. (and you know I don't comment any more) Now there's a book for you to write to students and medical personnel in what ever facet of the field they are in. Empathy.. Man, I am sure that student never forgot that moment. Good!

In the end, I wonder if your tirade at the students was a useful or the best approach. You certainly were in attack mode, which I would not normally think is the best for teaching.I can remember points of my early medical education when frankly I didn't know what the hell I was doing -- it would not have been helpful to me to get a chewing out by the surgeon-son of a patient.As medical director of a rehab unit, from time to time I observe troublesome interactions between various staff and patients + families. I've learned how difficult it is to try to help the staff learn from what I see because of my authoritative position, even though I'm not responsible for their hiring or firing. So usually I will enlist the head nurse to try to work on the problem process and/or staff member.

I could not agree with you more! Patients are people and more often than not scared people!

Imagine how different a patient would react if EVERY hospital staff member (Dr.'s and others) would first introduce themselves, describe their their role, (Nurse, Dr's. Tech), why they are here and what they are going to do.

I remember one time as an RT making rounds with our Medical Director. With no hesitation what so ever, he undid the gown of a 70 year old lady. lowered the gown exposing her breasts, and applied his stethoscope to her chest, all the while talking to me, not the patient.

No hand washing, no explaination, no clean stethoscope, no dignity and whoa, no permission to do this in front of me!

Afterwards I indicated that I would not appreciate that being done to my mother/wife/girlfriend.

You know---what you described is not at all unusual. I have decided that to a large degree medical practitioners have become accustomed to the nature of the hospital and what happens there. What they lose sight of is that for most patients/patient families a surgery or hospitalization is a special occasion. We watch and listen to everything....we remember it. Hosptials seem to be really big on S O P (standard op procedure)while patients all come with different situations. I would argue that most of my complaints over the years center around failure to communicate. The surgeon does not consult with pain center doc or GP, the pediatric specialist and pediatrician don't collaborate, the nursing staff is tense with the doc or afraid to call him/her. Nobody preps you for what to expect at home. (It would be great to have all of the supplies/etc you need before you take the sick/injured home) Coordinating a loved one's care is a lot like herding cats...not an easy job

During the ultrasound of my (very) swollen thyroid two years ago, the person doing the ultra-sounding (who didn't introduce herself or give her job, so I have no idea) kept going back to one place. Then said "Oh my god" in a startled voice. Then excused herself, leaving me laying on the table, and told me stay as still as I could while she was gone.

Eventually, she came back with another woman who didn't introduce herself and picked up the wand again and just started in "right there, you see that? It doesn't look like a shadow, but I'm not sure if it's the machine."The other lady came around the bed and scolded me sharply "Hold still, please." then addressed Anonymous Tech #1. "No, I don't think so. Did you get it?""Yes, I got two good shots.""Ok, good."Anonymous Tech #2 left without another glance at me. #1 put down the wand again and followed her out. I could hear them talking outside the door, but not what they were saying.

Tech #1 came back in, overly-cheerful and gave me a cloth to wipe the goo off of my neck."There we go, you're all done!"I sat up and just waited for a minute, but she seemed to be very busy cleaning off the machine.

I said "I realize that you can't tell me anything... but could you just tell me, unofficially, what that MIGHT have been? What you MIGHT have seen? I promise that I won't take it as a diagnosis or anything. Did things look ok?"

She briefly glanced up from the machine. "Oh no. We're not allowed to tell you anything. The radiologist should be giving you a call on Monday."

I never did get a call. I finally got through to someone nearly a week later(I have no idea what their job was, either) and she told me that there wasn't anything to worry about, and that my results had been passed on to my E-N-T, but that there wasn't anything alarming in it. That I hadn't been called or called back because there hadn't been anything out of what they would normally expect to see.

Later, after the surgery, my girlfriend filled out the meal card for me as I just sort of sat there and drooled. I had the right side of my thyroid out as well as my tonsils, so I wasn't in much shape to do anything. The doc left orders for a liquid or very soft supper. My girlfriend noted on the diet sheet that I was very allergic to citrus fruits. Even spelled them out - NO lemon. NO orange juice. NO lime.

For supper, I was served a full pot-roast meal with chunky potatoes and carrots and not even any broth.I was still fuzzy, and I figured that they wanted me to try to eat what I could and to not baby my throat.

Yeah, I have no idea what I was thinking, either, but it was only like 4 hours after surgery, and I was pretty out of it.

I only managed a few bites before it hurt bad enough that I was crying, and I didn't tell anyone because I thought that it was my fault.

Later, I was brought a cup of tea with a slice of lemon floating in it.

Breakfast was toast with marmalade and a glass of orange juice, since I had said that supper was "too heavy" for me.

I had told everyone at every opportunity that I am a diet-controlled diabetic, but during my entire stay, nobody took a reading that I'm aware of. Every time I mentioned it, I was brushed off as soon as I said that I didn't take actual medication for it.

The people at the hospital were very nice, I'm sure, but the things that were tiny lapses to someone somewhere down the line (like a cheerful slice of lemon in a cup of hot tea) could have had a huge impact on me. I don't want to deal with healing from surgery AND have a mouthful of blisters to deal with.

i feel the need to make a few comments.firstly, i once said i was impressed with dr schwab for the example he is concerning how to be human while being a doctor. i repeat that. you are truly something to aspire to.secondly, greg p. i must disagree. i think that the good doctor's response was perfect and well aimed. he did not chew out the student, but rather took down the pricks in front of the student. anyway, he is a surgeon. bloody hell, i would have really taken someone apart. i think he showed restraint or incredible tact. well done. i stand in salute to you.

recently a family member went through the process of finding out he had lung cancer. (histology came in yesterday). in such a small town, it was my physician friend that started the diagnosis process and my thorax friend that got the biopsy. i visited him every day he was in hospital. i sat with his wife while he was in theater, just to be there because i would hate to be alone in her situation. i listened when she cried. i felt. and i'm also a surgeon. (only doctors will understand that sentence sid).

i think that to ever elevate yourself above your patients is pathological. to me to feel my own mortality as my patients suffer and die is a priveledge.

This is a very moving story that serves as a perfect example of how, despite the fact most physicians are very good people with their minds and hearts in the right places, some are arrogant or at least absent in their patient contact. A number of people are in medicine in my family in various ways, and we know the stress of working in an inpatient environment. However, that's no excuse for brash words or no words at all to pateints. (Incidently, I am the guy who's LiveJournal you kindly commented on after I mentioned you blog there.)

When I was in the ED at a local hospital with acute abdominal pain, most of the staff were caring if somewhat rushed—which was fine. In the ED I expect "rushed". However, one resident more or less talked down to me . . . until I reminded him that despite looking very young, that I too am a professional . . . and unlike his PGY-3 self, I am boarded in my field already. I don't think he meant any harm though or even to be arrogant: I think that most physicians when rushed (esp younger ones) tend to overlook the human side of contact and forget that allopathy isn't just about getting tests back from the lab and writings scripts for Cetirizine.

Good for you! I think that student probably did want to acknowledge your parents. You taught him a lesson that he probably never forgot and hopefully treats his patients empathetically. Those docs needed their come uppins - shame on them!

"I" WANT to know what that lady's obvious concern was! How could he not pick that up or did he just not want to because he did know the answers? But what if he was missing something important? You must have been wondering what she was going to say. And just to relieve her possible anxiety or concern - just give her a minute - Gee!

I have seen nurses do that before and it is too bad. Even Lab techs, x-ray etc. - it's like they forget they have more than a chest pain or a knee there - they forget there is a whole person.

I used to be bothered by how "some" medical staff including the squads bringing them, talked in front of the patients that came to the ER from the nursing home if they had dementia or for some reason believed the patient didn't understand because they seemed unresponsive. The hearing is the last to go. How do they know what another is processing in their spirit even if it is a momentary offense that the patient would forget in the next minute? What about respect for one's Dignity?

One night a Doc was saying something really cruel as a joke about an elderly patient who he perceived to be "gorked" because her eyes were closed and she didn't talk. Well...tears started to come out the corners of her eyes, rolling down her cheek onto the pillow. :(

Then there was another lady who was a frequent flier who was always brought in with SOB from COPD. The squad members would usually say something derogatory about her being back AGAIN when rolling her into the ER - like she wasn't even there. One night one guy was particularly offensive and I ignored him and jumped right up and in to say,"Hi Mrs ... - I'm so sorry your not feeling well tonight. It must feel AWFUL when you feel like you can't breathe!" She looked at me over her oxygen mask like she appreciated what I had said. I ALWAYS treated her with respect and tried to do what I could to help make her more comfortable when staff was tied up. More often then not- she was admitted. I also understand the burden of frequent fliers to staff and squads but she was old, poor and didn't have transportation and she felt like she couldn't freaking breathe!

Most of the time most staff and transporters are compassionate, Every now and then though...

Probably wouldn't hurt to take some reminder classes!

Sorry so long - again Dr S. but I have always been a champion for the underdogs and go out of my way to treat people with respect.

I do have a question about Coumadin and that is do all people run the risk of stroking out if they stop the blood thinners? I Know a lady in her mid 70s who went in to SDS for a routine colonoscopy and so she had to stop the coumadin but doing so caused a stroke during the procedure. She is much better now at 1 year later. She had been on it for approximately 30 years.

What is a patient and doctor to do in that situation? Avoid getting any invasive procedures? Her son said "That's it - she's never doing that again."

I guess it is one of those darned if you do and darned if you don't situations.

You had the advantage because you had the confidence of being a doctor who knew the environment very well. Pity the poor patient and his unsophisticated family in the same situation. Even if they felt slighted and wanted to punch the offending doctor in the nose, they wouldn't have dared to say anything for fear of reprisal - real or imagined.

greg: whereas I was addressing the student, I was speaking to the attending. I think everyone there got that. And whereas I can't claim that if there'd been time to contemplate my response (maybe read some journals, have a conference) it would have been exactly the same, I think it was less a "chewing out" than a real-time object lesson. My general point is that to be a fly on the wall would be an eye opener for most heath care professionals. Communication, more often that it ought, stinks.

seaspray: the risk of stopping coumadin depends on why it's being taken. It's always matched against the benefit of the procedure being contemplated. We try to time the cessation just right, and often cover with a short-acting anticoagualant. It doesn't always work out well; usually, it does.

Wow. Imagine the difference is all doctors could look at their patients, with all their messy emotional/psychological dysfunction and not fear, not avoid, just love them and accept them and be there.

You have saved many lives in your career. You have performed elegant handiwork on lots of bodies, but I bet your patients remembered the kindness and the understanding long after they forgot what the operation was about.

You have the capacity to connect with people. Most doctors today are afraid of their patients or afraid of commitment or maybe just lazy. I hope that you can get involved with educating them that people can be enjoyed instead of endured. Thanks for your excellent writing.

Amen to everything you said. I immediately assumed the reason you were talking to the student, aiming your indignation at him, was because of all the gaggle in the entourage, he was the one that would be the most likely to actually have a chance of real change; while anything is possible, I doubt the attending thought anything except "typical surgeon, trying tell me how to do medicine with my patients."

I've already been there as a patient with a couple of surgeries, but having a father go through end-stage liver disease and a succesful transplant--all after I knew I was going to medical school (meaning, I was already observing, taking mental notes)--was more education in many ways than I've gotten so far.

In December 2005 a Jules Stein ophthalmologist openly accused me of fabricating my monocular double vision. blink Then very brazenly stated to myself and my husband that she would stake her career on the fact that there was absolutely nothing wrong with my eyes.

Three weeks ago, post-surgery pit surgery [3cm tumor], all of the swelling fell off of me. The swelling in my eyes resolved and so did the double vision.

I'm debating whether I should let her know that her new career anxiously awaits.

Good for you Doc! I went through the same situation with my elderly parents several times.I can assure you that there is a Hospital Admin. & Medical Director in West Texas that are still walking funny after I ripped them a new --- for the way their ED Doc treated my parents like they were old fools.I have been in health care for 22 years and I have witnessed the good, the bad and the ugly. When I started out the vast majority of Doc's were good people.Today,I wouldn't give you a $1.99 for half of them out there. I feel sorry for the vast majority of elderly patients out there who have no family around to advocate for them in these situations. Cheers to the good Doc's left!

as a RN, it's a breath of fresh air to read a MD advocating for empathy. i always treat my patients with dignity and respect. they are vulnerable enough just being a patient in a hospital. i've had a similar experience occur to one of my patients as an entourage of med students with a senior came in for rounds. the patient was left in tears, after comforting the patient for a couple of minutes, and i ran after the group in the hallway and basically said what you said in your post, but in fewer words. luckily the attending had enough shame to go back to the patient to apologize.

In our endless quest for understanding of the anatomic and physiologic cause of disease we have deluded ourselves into thinking that disordered anatomy and physiology are what disease is about. We treat it as such, and in hospitals all too often name it....the lung cancer in 514-2 and the infected post TKA down the hall.The reality is that we should be caring for patients, who happen to have disordered anatomy or physiology, rather than reducing the issue beyond the level of the person. Even the most specialized of the specialized, the world expert in listening to S3 in elderly male patients who also happen to have enlarged prostates, should take the time to acknowledge the patient and the patients fears. To do so is only human, and humanism is really at the core of what it means to be a doctor. I'm not sure how we've managed to loose that it much of 'modern medicine' but we have, and it worries me. It should worry everyone who plans on aging, and needing medical care in their lives...Dr. J.

Where were all the good doctors when my grandma laid dying in the hospital and no one bothered to tell the family what the **** was going on? And where was the compassion for the children involved? I was the oldest and I had just turned 13 at that time, and I would've greatly appreciated even a nurses' assistant coming up and telling me "your grandma's in bad shape but we're doing everything we can to help her" sometime during her stay. Instead, she died alone, with only her children beside her, no one trying to make her - or her family - feel like every reasonable measure had been taken to try to help her. Granted, she'd been in and out of the hospital a lot, but she still deserved better. And her family deserved better too. And what about those nurses who just cut her insulin off, instead of calling the doctor for clarification on his instructions? The medical profession failed my family, but I don't hold it against everyone. I just wish that more were as thoughtful as the ones here. Just a thought, remember we're ALL humans, please!

I congratulate you Dr Schwab. I have worked as an RN in teaching hospitals for the past twenty years. This sounds Oh so familiar. I am so glad that you addressed the behavior with the students right after it happened. There is no doubt in my mind that if they remembered anything that week it would have been that encounter. Hopefully it impacted their future practice.

About Me

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.